Surgical infections costly in lives, days, dollars

Briggs JP, Kirkland KB, Trivette SL, et al. The impact of surgical-site infections in the 1990s: Attributable mortality, excess length of hospitalization, and extra costs. Infect Control and Hosp Epidemiol 1999; 20:725-730.

Patients who develop surgical site infections (SSIs) are twice as likely to die, and those who survive will have longer and costlier hospitalizations than non-infected patients, the authors report. The total excess hospitalization and direct costs attributable to SSIs were 12 days and $5,038, respectively.

"If our estimates of the impact of SSI are applied to the entire United States, SSIs are responsible for approximately 20,000 in-hospital deaths and cost hospitals over $3 billion each year for inpatient care alone," the authors emphasized. "Infection control programs that include SSI surveillance coupled with feed-back to surgeons regarding their infection rates are effective in reducing the rate of SSI. Our study demonstrates both the enormity of the human and financial costs associated with SSI and the benefits to patients and the size of potential savings to hospitals if effective prevention programs are instituted and maintained."

To determine mortality, morbidity, and costs attributable to SSIs in the 1990s, they matched a cohort of patients with SSIs one-to-one with patients without SSIs at a 415-bed community hospital. Overall, 225 pairs of patients with and without SSIs were matched on age, procedure, date of surgery, surgeon, risk index (from the Centers for Disease Control and Prevention National Nosocomial Infection Surveillance System), mortality, excess length of hospitalization, and extra direct costs attributable to SSIs. Of the 225 pairs, 20 infected patients (7.8%) and nine uninfected patients (3.5%) died during postoperative hospitalization. In addition, 74 infected patients (29%) and 46 uninfected patients (18%) required ICU admission.

The median length of hospitalization was 11 days for infected patients and six days for uninfected patients. The extra hospital stay attributable to SSI was 6.5 days. The median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. The excess direct costs attributable to SSI were $3,089. Among the 229 pairs who survived the initial hospitalization, 94 infected patients (41%) and 17 uninfected patients (7%) required readmission to the hospital within 30 days of discharge. When the second hospitalization was included, the total excess hospitalization and direct costs attributable to SSI were 12 days and $5,038, respectively.

"As more patients undergo outpatient and short-stay surgical procedures, fewer SSIs are detected prior to discharge," the authors noted. "This trend may in turn lead to underestimates of the rate of SSI and of the human and economic costs of such infections. Our study demonstrates the enormous negative impact that SSIs continue to have and the importance of looking beyond the initial postoperative hospitalization to determine the total costs of these infections." Indeed, SSIs at the hospital accounted for five deaths, a total of 107 days in the ICU, 920 days of hospitalization, and $473,997 in direct costs annually. SSI patients are more than five times more likely to be readmitted to the hospital, with many ending up in intensive care units, they noted.

"[Infection control] programs that reduce the incidence of SSI can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals," the authors concluded.